PLEASE COMPLETE THE INFORMATION BELOW TO VERIFY YOUR INSURANCE COVERAGE

ALL INFORMATION SUBMITTED IS COMPLETELY CONFIDENTIAL

Name *
Name
Phone
Phone
Seeking treatment for: *

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In compliance with HIPPA regulations, we may only contact you regarding confidential health matters in ways that you explicitly authorize. By providing the above contact information, you are authorizing us to contact you via that method. The more ways we have to contact you, the more quickly you can get your answer. For your privacy, select the method least likely to be checked by other parties. By submitting this form, you are explicitly authorizing us to use the information supplied to contact your insurance provider for the purpose of verifying eligibility for insurance benefits for the purposes stated above. The above information will also be used by an Admissions Coordinator at The Augustine Recovery Center to provide you with treatment options. Under no circumstances will your confidential information be shared with third parties or used for any purpose other than stated herein. Meeting with an Augustine Recovery Center financial counselor is part of our initial screening and admissions process, to make sure you understand treatment fees and payment options. Any treatment cost not covered by insurance or other benefits is your financial responsibility. We are dedicated to making your experience at The Augustine Recovery Center as welcoming and supportive as possible, including guiding you through the financial process.